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Effective contraceptive counseling with adolescents in a nurse-based setting
Nurs Clin N Am 37 (2002) 499–512
Effective contraceptive counseling with adolescents in a nurse-based setting Polly F. Cromwell, MSN, RN, CPNPa,*, Alison Moriarty Daley, MSN, RN, CS, PNPb,c a
University of Texas-Houston Medical School, Department of Pediatrics, Divisions of Adolescent Medicine and of Nurse Practitioners, 6431 Fannin St./MSB 3.149, Houston, TX 77030, USA b Yale University School of Nursing, Master’s Program, P.O.Box 9740, 100 Church Street South, New Haven, CT 06536-0740, USA c Yale-New Haven Hospital Adolescent Clinic, 20 York Street, New Haven, CT 06504, USA
Reproductive health issues are common for adolescents. The most recent Youth Risk Behavior Survey, a nationally representative survey of students in grades 9–12, found that 46% of students have had sex. Not surprisingly, the percentage was lowest among ninth graders (34%), with an increase by senior year to 61%. Approximately 5% of all high school students reported having been pregnant or having gotten someone pregnant, including 3% of ninth graders and 7% of seniors. Of concern, only 18% of students reported that they or their partner were using oral contraceptive pills (OCPs) at last sexual intercourse, whereas 58% of students reported condom use [1]. Nurses are often on the frontline with teenagers, whether in the school nurse’s office, a community clinic or private practice, a medical or psychiatric hospital, or an out-patient specialty service. Therefore, they serve an important role in identifying adolescents in need of reproductive health services, in providing comprehensive education and counseling on reproductive health issues, and in helping teens access appropriate services. This article presents an overview of the common methods of contraception used by adolescents, with a focus on effective counseling. Background Abstinence, either primary or secondary, is the safest and most effective way to prevent pregnancy. Though abstinence should always be encouraged, * Corresponding author. E-mail address: [email protected] (P.F. Cromwell). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 0 7 - 5
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a goal is to help adolescents prevent unintended pregnancy and the transmission of sexually transmitted infections (STIs). Teens need an effective method of contraception each and every time they have sex. In the 1995 National Survey of Family Growth, of those teenagers who reported contraceptive use, 44% used OCPs, 37% used condoms, 11% used depot medroxyprogesterone acetate (DMPA), and 8% used other methods [2]. OCPs and DMPA, both hormonal methods of contraception, are among the most efficacious (Table 1). Condoms, although not as effective in preventing pregnancy, are important in preventing the transmission of STIs, and teenagers who use hormonal contraceptive methods should be counseled to use condoms as well. In addition to the three most commonly used methods, we review emergency contraception, a one-time method of hormonal contraception, and medroxyprogesterone acetate and estradiol cypionate (MPA/E2C), a new monthly injectable hormonal product that is marketed under the trade name LunelleÒ. Health care visit for contraception Hormonal methods of contraception require a visit with a health care provider. At the visit, a thorough history must be taken to determine which method is the most appropriate choice. This will include a personal and family past medical history to identify any significant health risks. The World Health Organization (WHO) has developed Comprehensive Medical Eligibility Criteria for Contraceptive Use that were updated in 2000 [3]. Tables 2 and 3 include the absolute and relative medical contraindications most applicable to adolescents for each method. For most healthy teenagers, the only absolute contraindications to hormonal contraception are pregnancy and undiagnosed irregular vaginal bleeding. The relative contraindications are situations or illnesses in which the benefits of using the method outweigh the proven or theoretical risks associated with its use. For most chronically ill teens, the physical and psychosocial risks of a pregnancy outweigh the theoretical risks of contraceptive use. The clinician should discuss with the patient which methods best match her social situation (see Box 1). Together, the patient and clinician can decide which method to try first, and what the back-up plan will be. Table 1 Efficacy of common contraceptive methods [8,12,21] Method
Failures per 100 ‘‘perfect’’ users in the first year (%)
Failures per 100 ‘‘typical’’ users in the first year (%)
Condoms OCPs DMPA MPA/E2C
3.0 0.1 0.3 0.1
14.0 3.0 0.3 0.1
DMPA, depot medroxyprogesterone acetate; OCPs, oral contraceptive pills; MPA/E2C, medroxyprogesterone acetate and estradiol cypionate.
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Table 2 Contraindications for OCPs and MPA/E2C [3,8,21] Absolute contraindications Pregnancy Undiagnosed irregular vaginal bleeding Hypertensiona Benign or malignant liver tumor Currently impaired liver function or liver disease Thrombo-embolic disease: deep vein thrombosis or pulmonary embolus Thrombo-embolic disease in first-degree relativeb Arterial cardiovascular disease (extremely rare in adolescents) Breast cancer (extremely rare in adolescents) Relative contraindications Diabetes mellitusc Migrained Sickle cell diseasee Smoking f a Who classifies as absolute, even if controlled [3]. Other experts classify as relative if controlled. b Who classifies as relative [3]. Other experts classify as absolute. c Absolute ONLY if with vascular disease [3]. Not the case with teens [8]. d Absolute ONLY if with aura and neurologic symptoms [3,8]. e Safety data outweigh theoretical risks [3,8]. f Absolute ONLY if age >35 years [3,8].
After the history is taken, patients need at least a partial physical exam, including vital signs, height and weight, and examination of thyroid gland, heart, and abdomen. Although common practice is to perform the breast and pelvic exams at the time of starting contraception, they are not required Table 3 Contraindications for DMPA [3,8,12] Absolute contraindications Pregnancy Undiagnosed irregular vaginal bleeding Severe coagulation disorders Past history of sex-steroid induced liver adenoma Breast cancer (extremely rare in adolescents) Relative contraindications Liver diseasea b Thrombo-embolic disease: deep vein thrombosis or pulmonary embolus c Cerebrovascular disease Age <18 years from bone density concernsd a Who classifies as relative [3]. Depending on severity; other experts classify as NOT a contraindication [8]. b Who classifies as relative [3]. Other experts classify as NOT a contraindication [8,12]. c Who classifies as risk outweighs benefit [3]. Other experts classify as NOT a contraindication [12]. d Who classify as relative [3]. Other experts classify as NOT a contraindication [8,12].
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Box 1 Screening questions to identify method of choice Do you know anyone who uses birth control? What method? What do they say about it? Have you heard anything good or bad about the different methods of birth control? Do you have trouble swallowing pills? (If YES, let me show you the pill, it’s a little one.) Have you ever taken a pill every day? Was it hard to remember? How will you remember to take a pill every day? Where will you keep the OCPs? Does anyone at home know you are taking OCPs? Can she/he help you remember? Is it easier to try a shot? Can you return to the clinic every 1-3 months for the shot? If your bleeding is irregular, will you or anyone else be concerned? If you feel hungrier, can you resist eating more? Do you like exercise? Would you consider working out more? Which method seems best to you and why? OCP, oral contraceptive pills. [4]. It is reasonable to delay the pelvic exam if the adolescent is extremely anxious about having it and there are no symptoms of a sexually transmitted infection (STI), or if the patient is not yet having sex. For the teenager who plans ahead and obtains birth control prior to initiating sexual activity, the exam can be delayed until she has had sex. During the exam in a sexually active patient, a Papanicolaou (Pap) test is obtained yearly, and STI screening is obtained at least yearly, depending on the patient’s risk factors.
Oral contraceptive pills Pharmacology Combination OCPs contain an estrogen and a progestin. There are also progestin-only pills, but these are rarely used by adolescents and are not reviewed. Ethinyl estradiol is the estrogen in almost all OCPs. Low-dose OCPs are any product with <50 mcg of estrogen per pill, and most contain 30–35 mcg of ethinyl estradiol. There are several 20-mcg pills available, but their use seems to be associated with breakthrough bleeding [5], a side effect that teenagers do not tolerate [6]. There are two general categories of progestins, the estranes and gonanes. The estranes include norethindrone and its derivatives. The gonanes include
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levonorgestrel, desogestrel and norgestimate. In general, there are few clinically proven differences between the progestins. OCPs containing desogestrel (Desogen, Ortho-Cept, Ortho-Tricept) have been implicated in an increase in venous thromboembolic events, a rare but serious side effect, thought to be related to the ethinyl estradiol-desogestrel combination and its potentiation of estrogenic effects [7]. Only OCPs containing norgestimate (Ortho-Cyclen, Ortho-Tricyclen) have been approved by the U.S. Food and Drug Administration (USDA) for the treatment of acne, but all OCPs improve acne and no one brand or progestin has been shown to be more effective than others in improving acne [8]. OCPs prevent pregnancy through a combination of effects modulated by the estrogen and progestin components: by inhibiting follicular development, by inhibiting the luteinizing hormone (LH) surge and preventing ovulation, by thickening the cervical mucus, and by producing a decidualized endometrium that is not conducive to implantation. Formulation OCPs are packaged as 21- or 28-day pill packs. Each pill in a 21-day pack contains hormones. At the end of the pack, the patient does not take pills for 7 days, during which time she will have a withdrawal bleed. In a 28-day pack, there are usually 21 hormone-containing pills followed by 7 placebo pills. The rationale for using 28-day packs, especially for adolescents, is that taking a pill every day is easier to remember than starting a new 21-day pack after a 7-day break. OCP cycles can be monophasic or triphasic. In monophasic pills, the doses of estrogen and progestin remain the same throughout the 21-day cycle. In triphasic pills, the amount of estrogen per pill and/or the amount of progestin per pill will vary over the 21 days. The current literature indicates there are no clinically important advantages or disadvantages between the monophasic and triphasic pills [8]. For most teenagers, low dose OCPs in a 28-day pack are the best choice. Monophasics may be preferable because the packaging is less confusing. Every hormone-containing pill is the same color instead of changing colors as the strength of the estrogen and progestin changes through the cycle [6]. Even though some texts advocate matching the patient to the pill [9], there are few clinically proven differences between brands [8]. Most clinicians prescribe one or two brands on a regular basis, and examples of some commonly used brands are found in Table 4. Counseling It is most helpful for the nurse, regardless of the setting, to have OCP samples available for hands-on counseling. First, the proper way to start the pills should be reviewed. It is important to point out the first pill, demonstrate how to get the pill out of the pack, and indicate the order in which
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Table 4 Examples of common low-dose OCPs Type of estrogen and progestin
Brand name
e.e. þ norethindrone
Ortho-Novum 1/35Ò Norinyl 1/35Ò
e.e. þ ethynodiol diacetate (a norethindrone-like progestin)
Demulen 1/35Ò
e.e. þ levonorgestrel
Lo-OvralÒ LevlenÒ Tri-phasilÒ
e.e. þ norgestimate
Ortho-CyclenÒ Ortho-TricyclenÒ
e.e ¼ ethinyl estradiol.
to take the pills. Most monophasics are ‘‘Sunday starts’’; the teen takes the first pill on Sunday if her period begins that day or, if her period begins during the week, she will start the Sunday of the upcoming weekend. Triphasic OCPs can either be started on the first day of the menses, and the pack labeled accordingly (show the teen that there are either stickers that mark the first day or a dial that is rotated to the first day); or started using the Sunday start plan. Adolescents are often so excited to have obtained OCPs that they start the first Sunday after the visit, without waiting for a menses. If the teen has started this way, she should continue to take the pills, but it will be important to verify that she got her menses after the 21 days of hormone-containing pills and is not pregnant. The first pack of OCPs provide effective contraception if, for monophasics, the pills are started within the first 5 days of the onset of menses or, for triphasics, if the pack is started on the first day of the period. If the monophasics are started after the fifth day of menses or the triphasics are started after the first day of menses, a back-up method of contraception is required for the first 7 days [6]. OCPs can be started immediately after a therapeutic abortion (the same day or on Sunday, depending on the pill pack). OCPs should be started in the third week postpartum if not breast-feeding and, especially with teens, not delayed until the 6-week checkup [8]. Other medications taken by the teen must be considered when starting an OCP, as drug interactions can occur. It is important to discuss with the teenager where she will keep the OCPs, and when she will take them. A time that is tied to a daily activity is ideal, for example when she is arranging her hair in the morning. Point out that the same time each day means around the same time each day, and that several hours leeway is allowed if, for example, she sleeps later on the weekends. Emphasize that, if the usual time is missed, the pill should be taken as soon as it is remembered. Also, it is helpful to review what she will say if the OCPs are found by a parent. Although teens can obtain contraception confidentially, parents are often perceptive and find the hidden OCPs. The
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nurse can help the teen prepare for that situation, and role-play possible responses. Common side effects should be reviewed. Bleeding between periods is common in the first few cycles of OCP use and usually resolves after 3 months of use. If it continues beyond the 3 months, first review with the teen whether there is a possibility of pills missed or taken late. Rarely will teenagers admit to skipping a pill but, when asked how many times they have doubled up, they may change the answer. If they have taken the pill daily, they should be encouraged to call the health care provider, who can prescribe additional estrogen for 7 days to stop the bleeding [6]. If the teen is nauseous during the first few months of pill use, she can take the pill either with food or at bedtime. Weight gain is a common concern of teens but usually not a significant problem [10]. The teen can be advised that she may feel hungrier as she starts the pills, and she needs to balance eating with exercise if she likes her current weight [6]. It is helpful to review orally and in writing what to do if pills are missed and to demonstrate the instructions using the pack. The instructions regarding missed pills are highlighted below (see Box 2) If two pills are missed, in addition to making them up, the adolescent should be counseled to use a back-up method of contraception for the next 7 days. If three pills are missed, the clinician can decide between starting a new pack on Sunday (the same day for triphasics), providing emergency contraception (EC), or both [8]. Any physical changes, whether real or imagined, may be blamed on OCP initiation, and a counseling session after the first month of use can help alleviate concerns. Blood pressure (rarely, there is an idiosyncratic rise) and weight should be checked, and pill use reviewed. Praise pill use, no matter how inconsistent, and strategize with the teen on ways to improve if daily use was problematic. Some adolescents will realize at this point that
Box 2 Making up missed pills [5,8] Try to take your pill around the same time each day. If you forget one pill and remember later the same day, take it as soon as you remember. If you forget one pill and do not remember until the next day, take both the missed pill and the next day’s pill together. Now you are caught up. If you forget two pills in a row take the two missed pills on the day you remember. The next day take the next two. Now you are caught up. If you forget three pills in a row, call your clinician immediately for advice.
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consistent pill taking is hard for them, and they may choose to switch to DMPA or MPA/E2C. Finally, adolescents have often heard from friends and relatives that OCPs cause cancer or sterility, or are ineffective. Everyone knows someone who got pregnant ‘‘on the pill.’’ It is important to bring these issues up, even if the adolescent does not. The teen can be reassured that OCPs are actually protective against ovarian and endometrial cancer [8]. Although there seems to be a slightly increased risk of breast cancer among young women who initiate OCP use as teenagers both during use and for 5 years after discontinuing, the actual numbers are very low because breast cancer is extremely rare in that age group [8]. Fertility returns within several months of discontinuing OCPs, often sooner, and when taken daily, OCPs are close to 100% effective [8]. The pregnant friend may not have been as good at taking a daily pill.
Depot medroxyprogesterone acetate Pharmacology DMPA, a form of progesterone, is an injectable long-acting method of contraception. When initiated within the first 5 days of the menstrual period, DMPA 150 mg is effective at preventing pregnancy for 13 weeks, although teens should be scheduled for a reinjection every 11–12 weeks to allow time for a missed appointment (or two) within the 13-week period. DMPA can be given at the time of a therapeutic abortion or, for teens who have delivered, prior to hospital discharge. DMPA is often the first choice for adolescents whose chronic illness may preclude the use of estrogen-containing contraceptives, for teens with sickle cell disease (DMPA may inhibit red blood cell sickling and crises), and for those who have difficulty remembering to take a daily pill [11]. DMPA prevents pregnancy through a combination of progestin-induced effects: inhibition of the LH surge and prevention of ovulation, thickening of the cervical mucus, and production of a decidualized endometrium. Counseling Adolescents are often scared to receive the first dose because it is an injection. They can be advised that, although many teens have been scared to receive the first shot, it is rare for them to refuse the second because of the pain of the first. Common side effects include breakthrough bleeding and minimal weight gain. Irregular bleeding, often light bleeding or spotting, is common with DMPA but decreases with increasing length of use. The majority of patients are amenorrheic by the end of the first year [12]. Adolescents who perceive the bleeding to be heavy or too persistent should be counseled to call their
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clinician, who can prescribe a short course of estrogen, or a low-dose OCP to stop the bleeding. The nurse should emphasize that there is treatment for irregular bleeding because teenagers are at risk of discontinuing DMPA if they think the bleeding cannot be controlled. An increased appetite is a progestational effect, and teens need to understand that it is the increased appetite that leads to an increase in food consumption that can result in weight gain. Although women on DMPA may gain weight [10,11], proper nutrition and exercise can prevent the problem. It is important for weight to be monitored at every visit, and nutrition and exercise counseling to be offered. Less commonly reported side effects include headache, bloating, and a decrease in libido, all subjective findings. Although there had been concern that DMPA use could lead to depression, data suggest that is not the case [12]. It is still unclear whether DMPA use causes a decrease in bone density, and whether that loss is reversible. A large study should be completed in 2003 and then recommendations, if any, can be made [12]. In one sample, 9% of teens reported galactorrhea. Such teens should be advised to inform their health care provider who may consider checking a prolactin level; however, reassurance and instructions to stop checking for leakage are usually the only interventions needed [13]. If an adolescent has missed her return appointment for the next injection, the clinician has several options. If the teen has not had sex since the end of the week 13 after the previous injection, she may receive DMPA. If she has had sex, she should be counseled to abstain from sex or use condoms for at least 2 weeks, so that she can receive the next injection after receiving a negative pregnancy test. It may take months for menses to return, and therefore it is not practical to wait for the next period to start DMPA. The teen may already be pregnant. The current generation of highly accurate urine pregnancy tests can usually detect pregnancy within 2 weeks of fertilization. If a teen has avoided the risk of pregnancy for at least 2 weeks, it is reasonable to reinject DMPA. Abstinence is a more reliable option than condom use: condoms break or may be used incorrectly. For adolescents who are worried about fertility, they can be reassured that half of all women who discontinue DMPA are pregnant within 10 months after the last injection, and that the remaining women become pregnant within another 18 months [12]. Although there is a delay in return of fertility, there is no association with infertility, often an adolescent concern.
Condoms Male condoms Latex condoms, the most common barrier method of contraception, are effective in the prevention of pregnancy and in the transmission of STIs. Latex condoms have several practical advantages for the teen. They are safe,
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easy to use, accessible, and affordable. Many communities have condoms available for free at school-based clinics, family planning clinics, and STI clinics. Condoms are also available in vending machines and in many stores. Polyurethane condoms are also available and are twice as strong as latex condoms. The polyurethane condom is thinner and thus increases sensitivity during sex. They have the added advantage of being safe for latex-sensitive patients. Disadvantages include the need for increased lubrication with use, increased cost, and increased noise during use [14]. Although most condoms contain the spermicide nonoxynol-9, there has been an association between nonoxynol-9 vaginal gel and an increased risk of HIV transmission (presumably from increased mucosal irritation as an entry mechanism), and, in the future, condoms may be spermicide-free [15]. Female condoms The female condom is also available over the counter and is an effective barrier method for pregnancy and STI prevention if used correctly. It is a polyurethane pouch with two flexible rings. One ring is inserted into the vagina and the second is left outside the vagina. Additional water or oilbased lubrication can be used if desired. The female condom may have the added benefit of providing an additional barrier of protection to the introitus during sex and decrease the risk of the transmission of infection. This method is more cumbersome and costly, however, than the male condom [14]. Counseling The overall use of condoms has increased dramatically, however, they are not used consistently [1]. Teens who believe their peers are using condoms [16], and those who feel their partner is supportive of condom use [17], have been shown to be more likely to use them. Adolescents should be taught how to use and store condoms properly. A new condom should be used for each sexual act, making sure that at least an inch is left at the end, free from air, to prevent breaking. Condoms must be placed on the erect penis before it is placed anywhere near an orifice, and not just prior to ejaculation, a fact many teenage males find hard to believe. Water-based lubrication can be used with latex condoms; however, it should be emphasized that oil-based lubricants will adversely effect the latex and may cause it to break. In addition, some intravaginal medications for yeast infections may be oil-based and can also cause breakage. Polyurethane condoms are not affected by oil-based lubricants or medications and can be used at any time. To demonstrate use, there are wooden penis models, but one’s hand or arm will do just as well. The benefit of using an arm is in showing how easily the condom stretches both horizontally and vertically; this is helpful for adolescent females to witness so they are not foiled by the classic line, ‘‘I’m just too big (to use a condom).’’Condoms should be stored at room temperature away from sharp objects that may cause a tear. The wallet in the back pocket is
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probably too warm a location and may lead to drying and subsequent cracking. Condoms should be kept readily accessible so that they are available when needed. The nurse should counsel both male and female teens to have condoms with them ‘‘in case’’ and emphasize that carrying condoms is a sign of responsibility, nothing more. The female condom may not be the first choice for most teens, but its use can be explained and demonstrated for those who are interested.
Emergency contraception Pharmacology/formulation EC is used to prevent pregnancy after an episode of unprotected sexual intercourse. There are two regimens: one consists of ethinyl estradiol 100 mcg, plus either norgestrel 1.0 mg or levonorgestrel 0.5 mg. The newer regimen is solely levonorgestrel 0.75 mg. The first regimen is 75–80% successful at preventing pregnancy, whereas the levonorgestrel regimen is successful 89% of the time. Both regimens are given as two single doses: the first dose within 72 hours of the incident and, ideally, as soon as possible; and the second dose 12 hours later [18]. The first regimen is either packaged as Preven, which contains two pills per dose, or can be made from existing OCPs (Table 5). The second regimen is packaged as Plan B, and contains one pill per dose. In addition to its higher efficacy, Plan B also causes less nausea and vomiting, a side effect of the estrogen in Preven. The method of action for both regimens is not totally understood. It most likely works from a combination of effects: a delay in follicular maturation yielding a delay or prevention of the LH surge and subsequent ovulation; and a disruption of the endometrial lining, which may or may not be enough of a change to prevent implantation [19]. Counseling Adolescents often engage in unanticipated and unprotected sexual activity. Nurses may be the first to hear from the teen about such an event, and emergency contraception is ideal for those situations. Teens who are
Table 5 EC with existing brands of OCPs OCP brand
Number of pills per dose
OvralÒ Lo-OvralÒ, NordetteÒ, LevlenÒ, LevoraÒ TriphasilÒ, Tri-levlenÒ, Tri-LevoraÒ AlesseÒ, LevliteÒ
2 4 4 5
EC, emergency contraception; OCP, oral contraceptive pill.
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abstaining should be informed of its availability ‘‘in case.’’ Other teens who may be candidates for EC include those who rely solely on condoms when the condom breaks, teens who have missed more than 3 OCPs, and those who are late for their DMPA injection [6]. It is not necessary to have a pregnancy test before taking EC, as it will not effect a viable pregnancy [20,21]. Teens who are sexually assaulted must be offered EC as part of the evaluation. The nurse can often help the teen pick the best time to take the initial dose. If the teen obtains the regimen from the clinician in the afternoon, it may be best to delay the first dose until early evening so that the second dose can be taken the next morning, instead of the middle of the night. Side effects include nausea and vomiting that are more common with the estrogen combinations than with levonorgestrel, and an antiemetic can be taken 60 minutes prior to the dose. Though some sources recommend repeating the dose if the teen vomits within 1 hour of administration, other sources state that there is no evidence of decreased efficacy unless vomiting occurs within minutes after ingestion of the dose [20]. The latter conclude that if vomiting is secondary to the effects of estrogen on the central nervous system, absorption has occurred by the time of vomiting [20]. Adolescents who use EC should see the health care provider 3 weeks later to address contraceptive needs and/or a pregnancy test if menses has not started.
Medroxyprogesterone acetate and estradiol cypionate Pharmacology MPA/E2C was approved for use by the USDA in October 2000. This method combines combines the ease of an injectable contraceptive with the regular bleeding pattern provided by an estrogen. Because estradiol cypionate is metabolized to estradiol which is indistinguishable from the body’s own estradiol, there are fewer adverse side effects than with OCPs. Most importantly, there is no increase in clotting factors, and, in studies thus far, no association with an increase in thromboembolic events [21]. Similar to OCPs, MPA/E2C prevents pregnancy through a combination of estrogen- and progestin-induced effects: inhibition of follicular development, inhibition of the LH surge and prevention of ovulation, thickening of the cervical mucus, and production of a decidualized endometrium [21]. Formulation MPA/E2C is given in a single intramuscular injection within the first 5 days of the menstrual cycle and then every 28–30 (not to exceed 33) days. It contains 25 mg of medroxyprogesterone acetate, plus 5 mg of estradiol cypionate. If given within the first 5 days of the cycle, it is effective in
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preventing pregnancy immediately. MPA/E2C should be given within 10 days of a therapeutic abortion and, per the labeling, between weeks 4 and 6 postpartum [21], although the OCP recommendations of week 3 postpartum seem safer in preventing another pregnancy [8]. Counseling MPA/E2C is a good choice for those who do not wish to take a daily pill and are willing to come for monthly injections. It is particularly well suited for those who wish to have a monthly withdrawal bleed and do not wish to make the 3-month commitment to DMPA. Bleeding is initially irregular. The first episode of bleeding occurs within 2–3 weeks following the first injection. With subsequent injections, a 5–6 day bleed comes once in the 28-day cycle, usually around day 22. A regular menstrual pattern is established in 80% of women by 3 months. Amenorrhea is uncommon [21]. Side effects include headache and breast tenderness, which generally resolve within 3 months of use. Weight gain may be possible. The limited data available in adult women show a 5-lb increase after 15 months of use, although nutrition and exercise counseling may prevent the gain. Ovulatory cycles are re-established within 2–4 months after the last injection, and 50% of women become pregnant within 6 months following discontinuation [21]. Summary Nurses serve a critical role in working with adolescents on reproductive health issues. Nurses must be knowledgeable and comfortable with providing counseling on contraceptive choices and decision making in order to meet the important goal of helping teens prevent unintended pregnancies. Acknowledgments The authors thank Will Risser, MD, PhD, for his critical review and editorial assistance. References [1] Centers for Disease Control and Prevention. CDC Surveillance Summaries. MMWR 2000;49(SS-5). [2] Piccininno LJ, Mosher WD. Trends in contraceptive use in the United States: 1982–1995. Fam Plann Perspect 1998;30:4–10,45. [3] Family and Reproductive Health Programme. Improving access to quality care in family planning. Medical eligibility criteria for contraceptive use, ed 2. Geneva: World Health Organization;2000. [4] Stewart F, Harper C, Ellertson C, et al. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs evidence. JAMA 2001;285:2232–9.
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[5] Kaunitz AM. Oral contraceptive estrogen dose considerations. Contraception 1998;58: 15S–21S. [6] Cromwell PF, Daley AM. Oral contraceptive pills: considerations for the adolescent patient. J Pediatr Health Care 2000;14:228–34. [7] Vandenbrouke JP, Bloemenkamp KWM, Middeldorp S, et al. Oral contraceptive pills and the risk of venous thrombosis. N Eng J Med 2001;344:1527–34. [8] Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility. ed 6. Baltimore, MD: Lippincott, Williams & Wilkins; 2000. [9] Dickey R. Managing contraceptive pill patients. ed 9. Durant, OK, Emis, Inc. Medical Publishers;1998. [10] Risser WL, Gefter L, Barratt MS, et al. Weight change in adolescents who used hormonal contraception. J Adolesc Health 1999;24:433–6. [11] Khoiny FE. Use of depo-provera in teens. J Pediatr Health Care 1996;10:195–201. [12] Kaunitz AM. Injectable depot medroxyprogesterone acetate contraception: an update for clinicians. Int J Fertil 1998;43:73–83. [13] Cromwell P, Anyan W. Letter to the Editor: Depot medroxyprogesterone acetate galactorrhea. J Adolesc Health 1998;23:61. [14] Stone KM, Timyan J, Thomas EL. Barrier methods for the prevention of sexually transmitted diseases. In: Holmes KK, Sparling PF, Mardh P, et al, editors. Sexually transmitted diseases, ed 3. New York: McGraw-Hill;1999. p. 1307–10. [15] Centers for Disease Control and Prevention. Notice to Readers: CDC statement on study results of product containing nonoxynol-9. MMWR 2000;49:717–8. [16] Brown LK, DiClemente RJ, Park T. Predictors of condom use in sexually active adolescents. J Adolesc Health 1992;13:651–7. [17] Weisman C, Plitcha S, Nathanson C, et al. Consistency of condom use for disease prevention among adolescent users of oral contraceptives. Fam Plann Perspect 1991;23: 71–4. [18] Roye CF, Johnsen JRM. Adolescents and emergency contraception. J Pediatr Health Care 2002;16:3–9. [19] Glasier A. Emergency postcoital contraception. N Eng J Med 1997;337:1058–64. [20] Hatcher RA, Zieman M, Watt A, et al. Managing contraception. Tiger, Georgia: Bridging the Gap Foundation;1999. [21] Wysocki S, Freeman S, Moore A, et al. New option in hormonal contraception: monthly combination contraceptive injection. Dayton, NJ: National Association of Nurse Practitioners in Women’s Health;2001.
Effective contraceptive counseling with adolescents in a nurse-based setting Polly F. Cromwell, MSN, RN, CPNPa,*, Alison Moriarty Daley, MSN, RN, CS, PNPb,c a
University of Texas-Houston Medical School, Department of Pediatrics, Divisions of Adolescent Medicine and of Nurse Practitioners, 6431 Fannin St./MSB 3.149, Houston, TX 77030, USA b Yale University School of Nursing, Master’s Program, P.O.Box 9740, 100 Church Street South, New Haven, CT 06536-0740, USA c Yale-New Haven Hospital Adolescent Clinic, 20 York Street, New Haven, CT 06504, USA
Reproductive health issues are common for adolescents. The most recent Youth Risk Behavior Survey, a nationally representative survey of students in grades 9–12, found that 46% of students have had sex. Not surprisingly, the percentage was lowest among ninth graders (34%), with an increase by senior year to 61%. Approximately 5% of all high school students reported having been pregnant or having gotten someone pregnant, including 3% of ninth graders and 7% of seniors. Of concern, only 18% of students reported that they or their partner were using oral contraceptive pills (OCPs) at last sexual intercourse, whereas 58% of students reported condom use [1]. Nurses are often on the frontline with teenagers, whether in the school nurse’s office, a community clinic or private practice, a medical or psychiatric hospital, or an out-patient specialty service. Therefore, they serve an important role in identifying adolescents in need of reproductive health services, in providing comprehensive education and counseling on reproductive health issues, and in helping teens access appropriate services. This article presents an overview of the common methods of contraception used by adolescents, with a focus on effective counseling. Background Abstinence, either primary or secondary, is the safest and most effective way to prevent pregnancy. Though abstinence should always be encouraged, * Corresponding author. E-mail address: [email protected] (P.F. Cromwell). 0029-6465/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 0 2 9 - 6 4 6 5 ( 0 2 ) 0 0 0 0 7 - 5
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a goal is to help adolescents prevent unintended pregnancy and the transmission of sexually transmitted infections (STIs). Teens need an effective method of contraception each and every time they have sex. In the 1995 National Survey of Family Growth, of those teenagers who reported contraceptive use, 44% used OCPs, 37% used condoms, 11% used depot medroxyprogesterone acetate (DMPA), and 8% used other methods [2]. OCPs and DMPA, both hormonal methods of contraception, are among the most efficacious (Table 1). Condoms, although not as effective in preventing pregnancy, are important in preventing the transmission of STIs, and teenagers who use hormonal contraceptive methods should be counseled to use condoms as well. In addition to the three most commonly used methods, we review emergency contraception, a one-time method of hormonal contraception, and medroxyprogesterone acetate and estradiol cypionate (MPA/E2C), a new monthly injectable hormonal product that is marketed under the trade name LunelleÒ. Health care visit for contraception Hormonal methods of contraception require a visit with a health care provider. At the visit, a thorough history must be taken to determine which method is the most appropriate choice. This will include a personal and family past medical history to identify any significant health risks. The World Health Organization (WHO) has developed Comprehensive Medical Eligibility Criteria for Contraceptive Use that were updated in 2000 [3]. Tables 2 and 3 include the absolute and relative medical contraindications most applicable to adolescents for each method. For most healthy teenagers, the only absolute contraindications to hormonal contraception are pregnancy and undiagnosed irregular vaginal bleeding. The relative contraindications are situations or illnesses in which the benefits of using the method outweigh the proven or theoretical risks associated with its use. For most chronically ill teens, the physical and psychosocial risks of a pregnancy outweigh the theoretical risks of contraceptive use. The clinician should discuss with the patient which methods best match her social situation (see Box 1). Together, the patient and clinician can decide which method to try first, and what the back-up plan will be. Table 1 Efficacy of common contraceptive methods [8,12,21] Method
Failures per 100 ‘‘perfect’’ users in the first year (%)
Failures per 100 ‘‘typical’’ users in the first year (%)
Condoms OCPs DMPA MPA/E2C
3.0 0.1 0.3 0.1
14.0 3.0 0.3 0.1
DMPA, depot medroxyprogesterone acetate; OCPs, oral contraceptive pills; MPA/E2C, medroxyprogesterone acetate and estradiol cypionate.
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Table 2 Contraindications for OCPs and MPA/E2C [3,8,21] Absolute contraindications Pregnancy Undiagnosed irregular vaginal bleeding Hypertensiona Benign or malignant liver tumor Currently impaired liver function or liver disease Thrombo-embolic disease: deep vein thrombosis or pulmonary embolus Thrombo-embolic disease in first-degree relativeb Arterial cardiovascular disease (extremely rare in adolescents) Breast cancer (extremely rare in adolescents) Relative contraindications Diabetes mellitusc Migrained Sickle cell diseasee Smoking f a Who classifies as absolute, even if controlled [3]. Other experts classify as relative if controlled. b Who classifies as relative [3]. Other experts classify as absolute. c Absolute ONLY if with vascular disease [3]. Not the case with teens [8]. d Absolute ONLY if with aura and neurologic symptoms [3,8]. e Safety data outweigh theoretical risks [3,8]. f Absolute ONLY if age >35 years [3,8].
After the history is taken, patients need at least a partial physical exam, including vital signs, height and weight, and examination of thyroid gland, heart, and abdomen. Although common practice is to perform the breast and pelvic exams at the time of starting contraception, they are not required Table 3 Contraindications for DMPA [3,8,12] Absolute contraindications Pregnancy Undiagnosed irregular vaginal bleeding Severe coagulation disorders Past history of sex-steroid induced liver adenoma Breast cancer (extremely rare in adolescents) Relative contraindications Liver diseasea b Thrombo-embolic disease: deep vein thrombosis or pulmonary embolus c Cerebrovascular disease Age <18 years from bone density concernsd a Who classifies as relative [3]. Depending on severity; other experts classify as NOT a contraindication [8]. b Who classifies as relative [3]. Other experts classify as NOT a contraindication [8,12]. c Who classifies as risk outweighs benefit [3]. Other experts classify as NOT a contraindication [12]. d Who classify as relative [3]. Other experts classify as NOT a contraindication [8,12].
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Box 1 Screening questions to identify method of choice Do you know anyone who uses birth control? What method? What do they say about it? Have you heard anything good or bad about the different methods of birth control? Do you have trouble swallowing pills? (If YES, let me show you the pill, it’s a little one.) Have you ever taken a pill every day? Was it hard to remember? How will you remember to take a pill every day? Where will you keep the OCPs? Does anyone at home know you are taking OCPs? Can she/he help you remember? Is it easier to try a shot? Can you return to the clinic every 1-3 months for the shot? If your bleeding is irregular, will you or anyone else be concerned? If you feel hungrier, can you resist eating more? Do you like exercise? Would you consider working out more? Which method seems best to you and why? OCP, oral contraceptive pills. [4]. It is reasonable to delay the pelvic exam if the adolescent is extremely anxious about having it and there are no symptoms of a sexually transmitted infection (STI), or if the patient is not yet having sex. For the teenager who plans ahead and obtains birth control prior to initiating sexual activity, the exam can be delayed until she has had sex. During the exam in a sexually active patient, a Papanicolaou (Pap) test is obtained yearly, and STI screening is obtained at least yearly, depending on the patient’s risk factors.
Oral contraceptive pills Pharmacology Combination OCPs contain an estrogen and a progestin. There are also progestin-only pills, but these are rarely used by adolescents and are not reviewed. Ethinyl estradiol is the estrogen in almost all OCPs. Low-dose OCPs are any product with <50 mcg of estrogen per pill, and most contain 30–35 mcg of ethinyl estradiol. There are several 20-mcg pills available, but their use seems to be associated with breakthrough bleeding [5], a side effect that teenagers do not tolerate [6]. There are two general categories of progestins, the estranes and gonanes. The estranes include norethindrone and its derivatives. The gonanes include
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levonorgestrel, desogestrel and norgestimate. In general, there are few clinically proven differences between the progestins. OCPs containing desogestrel (Desogen, Ortho-Cept, Ortho-Tricept) have been implicated in an increase in venous thromboembolic events, a rare but serious side effect, thought to be related to the ethinyl estradiol-desogestrel combination and its potentiation of estrogenic effects [7]. Only OCPs containing norgestimate (Ortho-Cyclen, Ortho-Tricyclen) have been approved by the U.S. Food and Drug Administration (USDA) for the treatment of acne, but all OCPs improve acne and no one brand or progestin has been shown to be more effective than others in improving acne [8]. OCPs prevent pregnancy through a combination of effects modulated by the estrogen and progestin components: by inhibiting follicular development, by inhibiting the luteinizing hormone (LH) surge and preventing ovulation, by thickening the cervical mucus, and by producing a decidualized endometrium that is not conducive to implantation. Formulation OCPs are packaged as 21- or 28-day pill packs. Each pill in a 21-day pack contains hormones. At the end of the pack, the patient does not take pills for 7 days, during which time she will have a withdrawal bleed. In a 28-day pack, there are usually 21 hormone-containing pills followed by 7 placebo pills. The rationale for using 28-day packs, especially for adolescents, is that taking a pill every day is easier to remember than starting a new 21-day pack after a 7-day break. OCP cycles can be monophasic or triphasic. In monophasic pills, the doses of estrogen and progestin remain the same throughout the 21-day cycle. In triphasic pills, the amount of estrogen per pill and/or the amount of progestin per pill will vary over the 21 days. The current literature indicates there are no clinically important advantages or disadvantages between the monophasic and triphasic pills [8]. For most teenagers, low dose OCPs in a 28-day pack are the best choice. Monophasics may be preferable because the packaging is less confusing. Every hormone-containing pill is the same color instead of changing colors as the strength of the estrogen and progestin changes through the cycle [6]. Even though some texts advocate matching the patient to the pill [9], there are few clinically proven differences between brands [8]. Most clinicians prescribe one or two brands on a regular basis, and examples of some commonly used brands are found in Table 4. Counseling It is most helpful for the nurse, regardless of the setting, to have OCP samples available for hands-on counseling. First, the proper way to start the pills should be reviewed. It is important to point out the first pill, demonstrate how to get the pill out of the pack, and indicate the order in which
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Table 4 Examples of common low-dose OCPs Type of estrogen and progestin
Brand name
e.e. þ norethindrone
Ortho-Novum 1/35Ò Norinyl 1/35Ò
e.e. þ ethynodiol diacetate (a norethindrone-like progestin)
Demulen 1/35Ò
e.e. þ levonorgestrel
Lo-OvralÒ LevlenÒ Tri-phasilÒ
e.e. þ norgestimate
Ortho-CyclenÒ Ortho-TricyclenÒ
e.e ¼ ethinyl estradiol.
to take the pills. Most monophasics are ‘‘Sunday starts’’; the teen takes the first pill on Sunday if her period begins that day or, if her period begins during the week, she will start the Sunday of the upcoming weekend. Triphasic OCPs can either be started on the first day of the menses, and the pack labeled accordingly (show the teen that there are either stickers that mark the first day or a dial that is rotated to the first day); or started using the Sunday start plan. Adolescents are often so excited to have obtained OCPs that they start the first Sunday after the visit, without waiting for a menses. If the teen has started this way, she should continue to take the pills, but it will be important to verify that she got her menses after the 21 days of hormone-containing pills and is not pregnant. The first pack of OCPs provide effective contraception if, for monophasics, the pills are started within the first 5 days of the onset of menses or, for triphasics, if the pack is started on the first day of the period. If the monophasics are started after the fifth day of menses or the triphasics are started after the first day of menses, a back-up method of contraception is required for the first 7 days [6]. OCPs can be started immediately after a therapeutic abortion (the same day or on Sunday, depending on the pill pack). OCPs should be started in the third week postpartum if not breast-feeding and, especially with teens, not delayed until the 6-week checkup [8]. Other medications taken by the teen must be considered when starting an OCP, as drug interactions can occur. It is important to discuss with the teenager where she will keep the OCPs, and when she will take them. A time that is tied to a daily activity is ideal, for example when she is arranging her hair in the morning. Point out that the same time each day means around the same time each day, and that several hours leeway is allowed if, for example, she sleeps later on the weekends. Emphasize that, if the usual time is missed, the pill should be taken as soon as it is remembered. Also, it is helpful to review what she will say if the OCPs are found by a parent. Although teens can obtain contraception confidentially, parents are often perceptive and find the hidden OCPs. The
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nurse can help the teen prepare for that situation, and role-play possible responses. Common side effects should be reviewed. Bleeding between periods is common in the first few cycles of OCP use and usually resolves after 3 months of use. If it continues beyond the 3 months, first review with the teen whether there is a possibility of pills missed or taken late. Rarely will teenagers admit to skipping a pill but, when asked how many times they have doubled up, they may change the answer. If they have taken the pill daily, they should be encouraged to call the health care provider, who can prescribe additional estrogen for 7 days to stop the bleeding [6]. If the teen is nauseous during the first few months of pill use, she can take the pill either with food or at bedtime. Weight gain is a common concern of teens but usually not a significant problem [10]. The teen can be advised that she may feel hungrier as she starts the pills, and she needs to balance eating with exercise if she likes her current weight [6]. It is helpful to review orally and in writing what to do if pills are missed and to demonstrate the instructions using the pack. The instructions regarding missed pills are highlighted below (see Box 2) If two pills are missed, in addition to making them up, the adolescent should be counseled to use a back-up method of contraception for the next 7 days. If three pills are missed, the clinician can decide between starting a new pack on Sunday (the same day for triphasics), providing emergency contraception (EC), or both [8]. Any physical changes, whether real or imagined, may be blamed on OCP initiation, and a counseling session after the first month of use can help alleviate concerns. Blood pressure (rarely, there is an idiosyncratic rise) and weight should be checked, and pill use reviewed. Praise pill use, no matter how inconsistent, and strategize with the teen on ways to improve if daily use was problematic. Some adolescents will realize at this point that
Box 2 Making up missed pills [5,8] Try to take your pill around the same time each day. If you forget one pill and remember later the same day, take it as soon as you remember. If you forget one pill and do not remember until the next day, take both the missed pill and the next day’s pill together. Now you are caught up. If you forget two pills in a row take the two missed pills on the day you remember. The next day take the next two. Now you are caught up. If you forget three pills in a row, call your clinician immediately for advice.
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consistent pill taking is hard for them, and they may choose to switch to DMPA or MPA/E2C. Finally, adolescents have often heard from friends and relatives that OCPs cause cancer or sterility, or are ineffective. Everyone knows someone who got pregnant ‘‘on the pill.’’ It is important to bring these issues up, even if the adolescent does not. The teen can be reassured that OCPs are actually protective against ovarian and endometrial cancer [8]. Although there seems to be a slightly increased risk of breast cancer among young women who initiate OCP use as teenagers both during use and for 5 years after discontinuing, the actual numbers are very low because breast cancer is extremely rare in that age group [8]. Fertility returns within several months of discontinuing OCPs, often sooner, and when taken daily, OCPs are close to 100% effective [8]. The pregnant friend may not have been as good at taking a daily pill.
Depot medroxyprogesterone acetate Pharmacology DMPA, a form of progesterone, is an injectable long-acting method of contraception. When initiated within the first 5 days of the menstrual period, DMPA 150 mg is effective at preventing pregnancy for 13 weeks, although teens should be scheduled for a reinjection every 11–12 weeks to allow time for a missed appointment (or two) within the 13-week period. DMPA can be given at the time of a therapeutic abortion or, for teens who have delivered, prior to hospital discharge. DMPA is often the first choice for adolescents whose chronic illness may preclude the use of estrogen-containing contraceptives, for teens with sickle cell disease (DMPA may inhibit red blood cell sickling and crises), and for those who have difficulty remembering to take a daily pill [11]. DMPA prevents pregnancy through a combination of progestin-induced effects: inhibition of the LH surge and prevention of ovulation, thickening of the cervical mucus, and production of a decidualized endometrium. Counseling Adolescents are often scared to receive the first dose because it is an injection. They can be advised that, although many teens have been scared to receive the first shot, it is rare for them to refuse the second because of the pain of the first. Common side effects include breakthrough bleeding and minimal weight gain. Irregular bleeding, often light bleeding or spotting, is common with DMPA but decreases with increasing length of use. The majority of patients are amenorrheic by the end of the first year [12]. Adolescents who perceive the bleeding to be heavy or too persistent should be counseled to call their
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clinician, who can prescribe a short course of estrogen, or a low-dose OCP to stop the bleeding. The nurse should emphasize that there is treatment for irregular bleeding because teenagers are at risk of discontinuing DMPA if they think the bleeding cannot be controlled. An increased appetite is a progestational effect, and teens need to understand that it is the increased appetite that leads to an increase in food consumption that can result in weight gain. Although women on DMPA may gain weight [10,11], proper nutrition and exercise can prevent the problem. It is important for weight to be monitored at every visit, and nutrition and exercise counseling to be offered. Less commonly reported side effects include headache, bloating, and a decrease in libido, all subjective findings. Although there had been concern that DMPA use could lead to depression, data suggest that is not the case [12]. It is still unclear whether DMPA use causes a decrease in bone density, and whether that loss is reversible. A large study should be completed in 2003 and then recommendations, if any, can be made [12]. In one sample, 9% of teens reported galactorrhea. Such teens should be advised to inform their health care provider who may consider checking a prolactin level; however, reassurance and instructions to stop checking for leakage are usually the only interventions needed [13]. If an adolescent has missed her return appointment for the next injection, the clinician has several options. If the teen has not had sex since the end of the week 13 after the previous injection, she may receive DMPA. If she has had sex, she should be counseled to abstain from sex or use condoms for at least 2 weeks, so that she can receive the next injection after receiving a negative pregnancy test. It may take months for menses to return, and therefore it is not practical to wait for the next period to start DMPA. The teen may already be pregnant. The current generation of highly accurate urine pregnancy tests can usually detect pregnancy within 2 weeks of fertilization. If a teen has avoided the risk of pregnancy for at least 2 weeks, it is reasonable to reinject DMPA. Abstinence is a more reliable option than condom use: condoms break or may be used incorrectly. For adolescents who are worried about fertility, they can be reassured that half of all women who discontinue DMPA are pregnant within 10 months after the last injection, and that the remaining women become pregnant within another 18 months [12]. Although there is a delay in return of fertility, there is no association with infertility, often an adolescent concern.
Condoms Male condoms Latex condoms, the most common barrier method of contraception, are effective in the prevention of pregnancy and in the transmission of STIs. Latex condoms have several practical advantages for the teen. They are safe,
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easy to use, accessible, and affordable. Many communities have condoms available for free at school-based clinics, family planning clinics, and STI clinics. Condoms are also available in vending machines and in many stores. Polyurethane condoms are also available and are twice as strong as latex condoms. The polyurethane condom is thinner and thus increases sensitivity during sex. They have the added advantage of being safe for latex-sensitive patients. Disadvantages include the need for increased lubrication with use, increased cost, and increased noise during use [14]. Although most condoms contain the spermicide nonoxynol-9, there has been an association between nonoxynol-9 vaginal gel and an increased risk of HIV transmission (presumably from increased mucosal irritation as an entry mechanism), and, in the future, condoms may be spermicide-free [15]. Female condoms The female condom is also available over the counter and is an effective barrier method for pregnancy and STI prevention if used correctly. It is a polyurethane pouch with two flexible rings. One ring is inserted into the vagina and the second is left outside the vagina. Additional water or oilbased lubrication can be used if desired. The female condom may have the added benefit of providing an additional barrier of protection to the introitus during sex and decrease the risk of the transmission of infection. This method is more cumbersome and costly, however, than the male condom [14]. Counseling The overall use of condoms has increased dramatically, however, they are not used consistently [1]. Teens who believe their peers are using condoms [16], and those who feel their partner is supportive of condom use [17], have been shown to be more likely to use them. Adolescents should be taught how to use and store condoms properly. A new condom should be used for each sexual act, making sure that at least an inch is left at the end, free from air, to prevent breaking. Condoms must be placed on the erect penis before it is placed anywhere near an orifice, and not just prior to ejaculation, a fact many teenage males find hard to believe. Water-based lubrication can be used with latex condoms; however, it should be emphasized that oil-based lubricants will adversely effect the latex and may cause it to break. In addition, some intravaginal medications for yeast infections may be oil-based and can also cause breakage. Polyurethane condoms are not affected by oil-based lubricants or medications and can be used at any time. To demonstrate use, there are wooden penis models, but one’s hand or arm will do just as well. The benefit of using an arm is in showing how easily the condom stretches both horizontally and vertically; this is helpful for adolescent females to witness so they are not foiled by the classic line, ‘‘I’m just too big (to use a condom).’’Condoms should be stored at room temperature away from sharp objects that may cause a tear. The wallet in the back pocket is
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probably too warm a location and may lead to drying and subsequent cracking. Condoms should be kept readily accessible so that they are available when needed. The nurse should counsel both male and female teens to have condoms with them ‘‘in case’’ and emphasize that carrying condoms is a sign of responsibility, nothing more. The female condom may not be the first choice for most teens, but its use can be explained and demonstrated for those who are interested.
Emergency contraception Pharmacology/formulation EC is used to prevent pregnancy after an episode of unprotected sexual intercourse. There are two regimens: one consists of ethinyl estradiol 100 mcg, plus either norgestrel 1.0 mg or levonorgestrel 0.5 mg. The newer regimen is solely levonorgestrel 0.75 mg. The first regimen is 75–80% successful at preventing pregnancy, whereas the levonorgestrel regimen is successful 89% of the time. Both regimens are given as two single doses: the first dose within 72 hours of the incident and, ideally, as soon as possible; and the second dose 12 hours later [18]. The first regimen is either packaged as Preven, which contains two pills per dose, or can be made from existing OCPs (Table 5). The second regimen is packaged as Plan B, and contains one pill per dose. In addition to its higher efficacy, Plan B also causes less nausea and vomiting, a side effect of the estrogen in Preven. The method of action for both regimens is not totally understood. It most likely works from a combination of effects: a delay in follicular maturation yielding a delay or prevention of the LH surge and subsequent ovulation; and a disruption of the endometrial lining, which may or may not be enough of a change to prevent implantation [19]. Counseling Adolescents often engage in unanticipated and unprotected sexual activity. Nurses may be the first to hear from the teen about such an event, and emergency contraception is ideal for those situations. Teens who are
Table 5 EC with existing brands of OCPs OCP brand
Number of pills per dose
OvralÒ Lo-OvralÒ, NordetteÒ, LevlenÒ, LevoraÒ TriphasilÒ, Tri-levlenÒ, Tri-LevoraÒ AlesseÒ, LevliteÒ
2 4 4 5
EC, emergency contraception; OCP, oral contraceptive pill.
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abstaining should be informed of its availability ‘‘in case.’’ Other teens who may be candidates for EC include those who rely solely on condoms when the condom breaks, teens who have missed more than 3 OCPs, and those who are late for their DMPA injection [6]. It is not necessary to have a pregnancy test before taking EC, as it will not effect a viable pregnancy [20,21]. Teens who are sexually assaulted must be offered EC as part of the evaluation. The nurse can often help the teen pick the best time to take the initial dose. If the teen obtains the regimen from the clinician in the afternoon, it may be best to delay the first dose until early evening so that the second dose can be taken the next morning, instead of the middle of the night. Side effects include nausea and vomiting that are more common with the estrogen combinations than with levonorgestrel, and an antiemetic can be taken 60 minutes prior to the dose. Though some sources recommend repeating the dose if the teen vomits within 1 hour of administration, other sources state that there is no evidence of decreased efficacy unless vomiting occurs within minutes after ingestion of the dose [20]. The latter conclude that if vomiting is secondary to the effects of estrogen on the central nervous system, absorption has occurred by the time of vomiting [20]. Adolescents who use EC should see the health care provider 3 weeks later to address contraceptive needs and/or a pregnancy test if menses has not started.
Medroxyprogesterone acetate and estradiol cypionate Pharmacology MPA/E2C was approved for use by the USDA in October 2000. This method combines combines the ease of an injectable contraceptive with the regular bleeding pattern provided by an estrogen. Because estradiol cypionate is metabolized to estradiol which is indistinguishable from the body’s own estradiol, there are fewer adverse side effects than with OCPs. Most importantly, there is no increase in clotting factors, and, in studies thus far, no association with an increase in thromboembolic events [21]. Similar to OCPs, MPA/E2C prevents pregnancy through a combination of estrogen- and progestin-induced effects: inhibition of follicular development, inhibition of the LH surge and prevention of ovulation, thickening of the cervical mucus, and production of a decidualized endometrium [21]. Formulation MPA/E2C is given in a single intramuscular injection within the first 5 days of the menstrual cycle and then every 28–30 (not to exceed 33) days. It contains 25 mg of medroxyprogesterone acetate, plus 5 mg of estradiol cypionate. If given within the first 5 days of the cycle, it is effective in
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preventing pregnancy immediately. MPA/E2C should be given within 10 days of a therapeutic abortion and, per the labeling, between weeks 4 and 6 postpartum [21], although the OCP recommendations of week 3 postpartum seem safer in preventing another pregnancy [8]. Counseling MPA/E2C is a good choice for those who do not wish to take a daily pill and are willing to come for monthly injections. It is particularly well suited for those who wish to have a monthly withdrawal bleed and do not wish to make the 3-month commitment to DMPA. Bleeding is initially irregular. The first episode of bleeding occurs within 2–3 weeks following the first injection. With subsequent injections, a 5–6 day bleed comes once in the 28-day cycle, usually around day 22. A regular menstrual pattern is established in 80% of women by 3 months. Amenorrhea is uncommon [21]. Side effects include headache and breast tenderness, which generally resolve within 3 months of use. Weight gain may be possible. The limited data available in adult women show a 5-lb increase after 15 months of use, although nutrition and exercise counseling may prevent the gain. Ovulatory cycles are re-established within 2–4 months after the last injection, and 50% of women become pregnant within 6 months following discontinuation [21]. Summary Nurses serve a critical role in working with adolescents on reproductive health issues. Nurses must be knowledgeable and comfortable with providing counseling on contraceptive choices and decision making in order to meet the important goal of helping teens prevent unintended pregnancies. Acknowledgments The authors thank Will Risser, MD, PhD, for his critical review and editorial assistance. References [1] Centers for Disease Control and Prevention. CDC Surveillance Summaries. MMWR 2000;49(SS-5). [2] Piccininno LJ, Mosher WD. Trends in contraceptive use in the United States: 1982–1995. Fam Plann Perspect 1998;30:4–10,45. [3] Family and Reproductive Health Programme. Improving access to quality care in family planning. Medical eligibility criteria for contraceptive use, ed 2. Geneva: World Health Organization;2000. [4] Stewart F, Harper C, Ellertson C, et al. Clinical breast and pelvic examination requirements for hormonal contraception: current practice vs evidence. JAMA 2001;285:2232–9.
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